Safety and Suitability of Infant Formula Manufactured from Extensively Hydrolyzed Whey Protein Compared to Intact Protein: A Combined Analysis of Two Randomized Controlled Studies

Our aim was to assess the nutritional safety and suitability of an infant formula manufactured from extensively hydrolyzed protein in comparison to infant formula manufactured from intact protein (both with low and standard protein content). We performed a combined analysis of raw data from two randomized infant feeding studies. An analysis of covariance (ANCOVA) model was used to determine the non-inferiority of daily weight gain (primary outcome; margin -3 g/day), with the intervention group as a fixed factor and geographic region, sex, and baseline weight as covariates (main model). The data of 346 infants exposed to the formula were included in the analysis. The sample size of the per-protocol analysis with 184 infants was too small to achieve sufficient statistical power. The lower limit of the 97.5% confidence interval (-0.807) of the mean group difference in daily weight gain (i.e., 2.22 g/day) was above the -3 g/day margin (full analysis set). Further anthropometric parameters did not differ between the infant formula groups throughout the study. Growth was comparable to breastfed infants. We conclude that the infant formula manufactured from extensively hydrolyzed protein meets infant requirements for adequate growth and does not raise any safety concerns.

Gastrointestinal Tolerance of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants

The evaluation of secondary parameters of a prospective, randomised, controlled, multicentre intervention trial aimed to analyse gastrointestinal tolerance of an infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF) in healthy term infants. Infants ≤ 25 days of age, who were exclusively formula-fed, were randomised to receive eHF or CF for at least three months up to 120 days of age. An exclusively breastfed reference group (BF) was included for descriptive comparison. Infants' gastrointestinal tolerance was evaluated based on stool parameters, the Amsterdam Infant Stool Scale (AISS), the Infant Gastrointestinal Symptom Questionnaire (IGSQ), and sleeping patterns. Of 359 infants included, 297 randomised (eHF: n = 149, CF: n = 148) and 41 BF infants completed the study per protocol. All tolerance parameters were comparable between eHF and CF. Stool was predominantly soft and yellow in colour. Stool was more frequently green in eHF than CF. BF infants had more frequent stools, which were mainly watery or soft and yellow, and comparable IGSQ scores (descriptive). Irrespective of group, all gastrointestinal and sleep parameters showed signs of maturation with increasing age. In conclusion, eHF showed gastrointestinal tolerance as good as CF in healthy infants. Both formulae were well-tolerated.

Safety and Suitability of an Infant Formula Manufactured from Extensively Hydrolysed Protein in Healthy Term Infants

We aimed to demonstrate that healthy term infants experience noninferior growth with infant formula manufactured from extensively hydrolysed whey protein (eHF) compared to intact cow's milk protein (control formula, CF). This prospective, randomised, double-blind, parallel-group, controlled, multicentre trial included healthy term infants who were exclusively formula-fed. Infants ≤ 25 days of age received eHF or CF for at least three months up to 120 days of age, with a follow-up until 180 days of age. A reference group included exclusively breastfed infants (BF). Of 318 infants randomised, 297 (148 CF, 149 eHF) completed the study per protocol. Weight gain up to 120 days of age was noninferior (margin -3.0 g/day) in eHF (28.95 (95% CI: 27.21; 30.68) g/day) compared to CF (28.85 (95% CI: 27.10; 30.61) g/day) with a difference in means of 0.09 g/day and a lower limit of the one-sided 97.5% CI of -0.86 g/day (p < 0.0001 for noninferiority testing). Weight gain remained comparable during follow-up. Further anthropometric parameters did not differ between the infant formula groups throughout the study. Growth was comparable in BF. No relevant safety issues were observed. To conclude, eHF meets infant requirements for adequate growth during the first six months of life and can be considered safe and suitable.

The Benefits of Breastfeeding on Child Intelligence, Behavior, and Executive Function: A Review of Recent Evidence

Background: The effects of breastfeeding on neurodevelopmental outcomes are unclear. Inconsistent findings have been reported and confounding factors make interpretation of studies difficult. The World Health Organization published a systematic review on breastfeeding and intelligence in 2013, demonstrating a positive association with improved performance on intelligence tests. The objective of this review is to explore published literature since 2013 to examine the association between breastfeeding, cognition, executive function, and behavior. Methods: Duplicate searches were carried out using Web of Science and OVID for publications between January 2012 and March 2022. Non-English articles and those not correcting for maternal IQ or home environment were excluded. Results: Twenty-three studies were included, examining the effects of breastfeeding on cognition (21), executive function (3), and behavior (6). Most studies showed a modest dose-dependent increase in cognitive scores in children who were breastfed, test score differences ranging from 0.19 to 0.96 points per month of breastfeeding comparing any breastfeeding, predominant and exclusive breastfeeding. Four out of six studies showed a positive correlation between breastfeeding and behavior. One out of three studies assessing breastfeeding and executive function showed a positive dose-dependent correlation. Discussion: Recent evidence demonstrates that breastfeeding has a small positive effect on IQ in later childhood. Evidence suggesting that breastfeeding is a protective factor in developing conduct disorders and achieving higher executive function is limited. Further research is required. Limitations include potential confounders and recall bias of breastfeeding.

Gut Microbiome Composition and Metabolic Capacity Differ by FUT2 Secretor Status in Exclusively Breastfed Infants

A major polymorphism in the fucosyltransferase2 (FUT2) gene influences risk of multiple gut diseases, but its impact on the microbiome of breastfed infants was unknown. In individuals with an active FUT2 enzyme (“secretors”), the intestinal mucosa is abundantly fucosylated, providing mutualist bacteria with a rich endogenous source of fucose. Non-secretors comprise approximately one-fifth of the population, and they lack the ability to create this enzyme. Similarly, maternal secretor status influences the abundance of a breastfeeding mother’s fucosylated milk oligosaccharides. We compared the impact of maternal secretor status, measured by FUT2 genotype, and infant secretor status, measured by FUT2 genotype and phenotype, on early infant fecal microbiome samples collected from 2-month-old exclusively breastfed infants (n = 59). Infant secretor status (19% non-secretor, 25% low-secretor, and 56% full-secretor) was more strongly associated with the infant microbiome than it was with the maternal FUT2 genotype. Alpha diversity was greater in the full-secretors than in the low- or non-secretor infants (p = 0.049). Three distinct microbial enterotypes corresponded to infant secretor phenotype (p = 0.022) and to the dominance of Bifidobacterium breve, B. longum, or neither (p < 0.001). Infant secretor status was also associated with microbial metabolic capacity, specifically, bioenergetics pathways. We concluded that in exclusively breastfed infants, infant—but not maternal—secretor status is associated with infant microbial colonization and metabolic capacity.

Acute-on-Chronic Subdural Hemorrhage Due to Late Vitamin K Deficiency

Vitamin K deficiency bleeding (VKDB) is closely associated with the hemorrhagic disease of the newborn (HDN) and can have a late onset, after one week of birth up to six months of age. It is a major concern in developing countries where vitamin K prophylaxis is not often given to newborns and can lead to significant mortality and morbidity. We report a case of a three-month-old child who was exclusively breastfed. He presented with repeated vomiting and was eventually diagnosed as a case of acute-on-chronic subdural hemorrhage. Timely diagnosis and surgical intervention played a key role in ensuring a favorable outcome for the child.

Infantile Tremor Syndrome With Movement Disorder: Current Perspective

Although infantile tremor syndrome is considered a rare entity, we present a typical case of this disorder. This case reinforces the association of infantile tremor syndrome with exclusive breastfeeding in infants and the absence of proper complementary feeding. A nine-month-old, irritable, listless, exclusively breastfed female presented with grade 2 malnutrition, tremors, hyperpigmentation, scarce scalp hair, and delayed developmental milestones. Laboratory investigations revealed macrocytic anemia and a low serum vitamin B12 value of 205 pg/dL. Cerebral and mild cerebellar atrophy were noted on the MRI brain scan. Accordingly, the patient was diagnosed with infantile tremor syndrome and treated with vitamin B12 and nutrient supplementation with zinc, magnesium, folic acid, and iron. The tremors improved and the child became responsive and interested in her surroundings. It is essential to recognize this condition at the earliest and initiate treatment. Basic interventions such as the promotion of proper nutrition, timely introduction of complementary feeding, and weaning practices are key factors in decreasing the incidence of this condition.

The Association of Formula Protein Content and Growth in Early Infancy: A Systematic Review and Meta-Analysis

This systematic review aimed to examine differences in growth outcomes between breastfed infants and infants fed with formula with different protein/energy ratios during the first six months of life. We conducted a systematic review in the PubMed, Web of Science, and Springer databases. Twenty clinical trials qualified for inclusion. We extracted data about the growth outcomes of infants who were exclusive breastfed or exclusively infant formula fed in the first six months and used a meta-analysis to pool the finding data. We categorized study formulas into four groups according to their protein content: <1.8, 1.8−2.0, 2.1−2.2, and >2.2 g/100 kcal. In the first month of life, growth was not different between formula- and breastfed infants. During 2−3 months of life, growth was faster in infants who consumed formulas with protein contents higher than 2.0 g/100 kcal. After 3 months, formula-fed infants grew faster than breastfed infants. Our meta-analysis indicated that the growth outcomes of infants fed with infant formula with a relatively low protein/energy ratios, compared with that a relatively high protein/energy ratio, were close to those of breastfed infants.

Antihistamine use during breastfeeding with focus on breast milk transfer and safety in humans: A systematic literature review

Current data on use of antihistamines during breastfeeding and risks to the breastfed infant are insufficient. The aim of this systematic review was to provide an overview of studies measuring the levels of antihistamines in human breast milk, estimating the exposure for breastfed infants and/or reporting possible adverse effects on the breastfed infant. An additional aim was to review the antihistamine product labels available in the European Union (EU) and the United States. We searched seven online databases and identified seven human lactation studies that included 25 mother-infant pairs covering cetirizine, clemastine, ebastine, epinastine, loratadine, terfenadine and triprolidine. In addition, one study investigated the impact of chlorpheniramine or promethazine on prolactin levels among 17 women, and one study investigated possible adverse drug reactions in 85 breastfed infants exposed to various antihistamines. The relative infant dose was below 5% for all antihistamines, ranging from 0.3% for terfenadine to 4.5% for clemastine. Most product labels of the 10 antihistamines with available information in both the EU and the United States reported lack of evidence and recommended to avoid use during breastfeeding. The knowledge gap on antihistamines and lactation is extensive, and further human studies are warranted to ensure optimal treatment of breastfeeding women with allergy.

Impact of the Duration of Breastfeeding on the Intelligence of Children: A Systematic Review with Network Meta-Analysis

Objective: To evaluate the impact of the duration of breastfeeding on the intelligence of children. Materials and Methods: Eight electronic databases were searched to identify studies that investigated the impact of breastfeeding on the intelligence of children. Data were pooled, and the ratio of means (RoM) and the corresponding 95% confidence interval (95% CI) were calculated using a pairwise meta-analysis and network meta-analysis. Risk of bias was assessed using a tool developed by the CLARITY group. Data were analyzed using R version 3.5.1. Results: A total of 15 studies with 12,316 subjects were included in the review. Half of the studies were at low risk of bias. A meta-analysis indicated that breastfed children had a score 1.04-fold higher in intelligence tests compared with those that had never been breastfed (RoM: 1.04, 95% CI: 1.02-1.06, p < 0.05). Evidence from a network meta-analysis indicated that breastfeeding for ≤6 months resulted in score 1.04-fold higher in intelligence tests (RoM: 1.04, 95% CI: 1.03-1.06, p < 0.05) and children breastfed for >6 months had a score 1.06-fold higher (RoM: 1.06, 95% CI: 1.05-1.08, p < 0.05) than children that had never been breastfed. Thus, breastfeeding for >6 months demonstrated a slightly higher score than breastfeeding for ≤6 months (RoM: 1.02, 95% CI: 1.00-1.04, p < 0.05). Conclusion: Breastfeeding could significantly improve the intelligence of children, with a duration of >6 months showing a slight but significantly higher intelligence score than for ≤6 months.

Longitudinal Profiles of Dietary and Microbial Metabolites in Formula- and Breastfed Infants

The early-life metabolome of the intestinal tract is dynamically influenced by colonization of gut microbiota which in turn is affected by nutrition, i.e. breast milk or formula. A detailed examination of fecal metabolites was performed to investigate the effect of probiotics in formula compared to control formula and breast milk within the first months of life in healthy neonates. A broad metabolomics approach was conceptualized to describe fecal polar and semi-polar metabolites affected by feeding type within the first year of life. Fecal metabolomes were clearly distinct between formula- and breastfed infants, mainly originating from diet and microbial metabolism. Unsaturated fatty acids and human milk oligosaccharides were increased in breastfed, whereas Maillard products were found in feces of formula-fed children. Altered microbial metabolism was represented by bile acids and aromatic amino acid metabolites. Elevated levels of sulfated bile acids were detected in stool samples of breastfed infants, whereas secondary bile acids were increased in formula-fed infants. Microbial co-metabolism was supported by significant correlation between chenodeoxycholic or lithocholic acid and members of Clostridia. Fecal metabolites showed strong inter- and intra-individual behavior with features uniquely present in certain infants and at specific time points. Nevertheless, metabolite profiles converged at the end of the first year, coinciding with solid food introduction.

The iron content of healthy diets for one day for breastfed babies and young children

AIMS

Early childhood anaemia due to iron deficiency is widespread in remote communities across northern Australia. Current recommendations for healthy food to complement breastfeeding at age 6 to 23 months include iron-rich and iron-enriched foods. An electronic nutrient analysis was undertaken to assess the iron content of hypothetical healthy diets for breastfed babies and young children aged 6 to 23 months in Australia, in comparison with their estimated requirements.

METHODS

Hypothetical diets for 1 day were developed that were consistent with the Foundation Diets for breastfed infants 6 to 12 months and for toddlers 13 to 23 months. Nutrient content was derived using the Australian Food Composition database in FoodWorks 10. The iron content of these two diets were compared with Estimated Average Requirements (EARs) and Recommended Dietary Intakes (RDIs) for iron for infants aged 7 to 12 months and children aged 1 to 3 years.

RESULTS

The iron content of the hypothetical diet for breastfed infants aged 6 to 12 months (5.8 mg) was less than the EAR (7 mg, 83%) and the RDI (11 mg, 53%). For young breastfed children aged 13 to 23 months, the iron content of the hypothetical diet was 4.4 mg; above the EAR (4 mg, 110%) but less than RDI (9 mg, 49%).

CONCLUSIONS

Breastfeeding has health and neurodevelopmental benefits for infants and young children that are particularly important in remote Australia where food insecurity and poor nutrition compromise health and wellbeing. Adequate iron intake is also important for neurodevelopment in early life but healthy diets for breastfed babies and young children may have insufficient iron content to meet requirements. The upcoming revision of the Australian Dietary Guidelines provides an opportunity to consider this issue.

Human behavior, not race or geography, is the strongest predictor of microbial succession in the gut bacteriome of infants

Colonization of the gastrointestinal tract with microorganisms during infancy represents a critical control point for shaping life-long immune-mediated disease susceptibility. Abnormal colonization or an imbalance of microbes, termed dysbiosis, is implicated in several diseases. Consequently, recent research has aimed at understanding ways to manipulate a dysbiotic microbiome during infancy to resemble a normal, healthy microbiome. However, one of the fundamental issues in microbiome research is characterizing what a "normal" infant microbiome is based on geography, ethnicity and cultural variations. This review provides a comprehensive account of what is currently known about the infant microbiome from a global context. In general, this review shows that the influence of cultural variations in feeding practices, delivery modes and hygiene are the biggest contributors to microbial variability. Despite geography or race, all humans have similar microbial succession during infancy.

Integrative Analysis of the Genes Induced by the Intestine Microbiota of Infant Born to Term and Breastfed

Nowadays, the integration of biological data is a major challenge for bioinformatics. Many studies have examined gene expression in the epithelial tissue in the intestines of infants born to term and breastfed, generating a large amount of data. The integration of these data is important to understand the biological processes involved during bacterial colonization of the newborns intestine, particularly through breast milk. This work aims to exploit the bioinformatics approaches, to provide a new representation and interpretation of the interactions between differentially expressed genes in the host intestine induced by the microbiota.

Feeding Infants Formula With Probiotics or Milk Fat Globule Membrane: A Double-Blind, Randomized Controlled Trial

Purpose: To evaluate effects on growth and infection rates of supplementing infant formula with the probiotic Lactobacillus paracasei ssp. paracasei strain F19 (F19) or bovine milk fat globule membrane (MFGM). Methods: In a double-blind, randomized controlled trial, 600 infants were randomized to a formula supplemented with F19 or MFGM, or to standard formula (SF). A breastfed group was recruited as reference (n = 200).The intervention lasted from age 21 ± 7 days until 4 months, and infants were followed until age one year. Results: Both experimental formulas were well tolerated and resulted in high compliance. The few reported adverse events were not likely related to formula, with the highest rates in the SF group, significantly higher than for the F19-supplemented infants (p = 0.046). Weight or length gain did not differ during or after the intervention among the formula-fed groups, with satisfactory growth. During the intervention, overall, the experimental formula groups did not have more episodes of diarrhea, fever, or days with fever than the breastfed infants. However, compared to the breastfed infants, the SF group had more fever episodes (p = 0.021) and days with fever (p = 0.036), but not diarrhea. Compared with the breastfed group, the F19-supplemented infants but not the other two formula groups had more visits/unscheduled hospitalizations (p = 0.015) and borderline more episodes of upper respiratory tract infections (p = 0.048). Conclusions: Both the MFGM- and F19-supplemented formulas were safe and well-tolerated, leading to few adverse effects, similar to the breastfed group and unlike the SF group. During the intervention, the MFGM-supplemented infants did not differ from the breastfed infants in any primary outcome.

Mothers' Thoughts and Feelings About Using a Pediatric Scale in the Home to Monitor Weight Changes in Breastfed Newborns

OBJECTIVE

To document mothers' thoughts and feelings about using a pediatric digital scale in their homes to monitor the weights of their newborns.

DESIGN

Cross-sectional design.

SETTING

A community hospital in the northeastern region of the United States.

PARTICIPANTS

Women (N = 63) who gave birth between August 2015 and September 2016 to healthy, full-term singleton newborns who were exclusively or predominantly breastfed at the time of hospital discharge.

MEASUREMENTS

We used an online survey to document participants' thoughts and feelings about the use of a pediatric scale in their homes to monitor the weights of their newborns every day for 2 weeks after birth.

RESULTS

Most participants (81%) had positive responses about the use of a pediatric scale in their homes. The collection of daily weight provided valuable knowledge (67%) and elicited feelings of reassurance (32%) and increased confidence in breastfeeding (14%). For some women (14%), using the scale caused concern about neonatal weight. If a participant believed her newborn was not feeding or gaining weight well (n = 9), she was more likely to have mixed or negative feelings about the scale (67%).

CONCLUSION

Women who breastfeed may benefit from the use of a pediatric scale in their homes. They may gain valuable knowledge and have increased confidence in breastfeeding if they monitor neonatal weight changes. Use of the scale may also alert mothers to early problems with newborn feeding or growth.

Alterations in human milk leptin and insulin are associated with early changes in the infant intestinal microbiome

BACKGROUND

Increased maternal body mass index (BMI) is a robust risk factor for later pediatric obesity. Accumulating evidence suggests that human milk (HM) may attenuate the transfer of obesity from mother to offspring, potentially through its effects on early development of the infant microbiome.

OBJECTIVES

Our objective was to identify early differences in intestinal microbiota in a cohort of breastfeeding infants born to obese compared with normal-weight (NW) mothers. We also investigated relations between HM hormones (leptin and insulin) and both the taxonomic and functional potentials of the infant microbiome.

DESIGN

Clinical data and infant stool and fasting HM samples were collected from 18 NW [prepregnancy BMI (in kg/m(2)) <24.0] and 12 obese (prepregnancy BMI >30.0) mothers and their exclusively breastfed infants at 2 wk postpartum. Infant body composition at 2 wk was determined by air-displacement plethysmography. Infant gastrointestinal microbes were estimated by using 16S amplicon and whole-genome sequencing. HM insulin and leptin were determined by ELISA; short-chain fatty acids (SCFAs) were measured in stool samples by using gas chromatography. Power was set at 80%.

RESULTS

Infants born to obese mothers were exposed to 2-fold higher HM insulin and leptin concentrations (P < 0.01) and showed a significant reduction in the early pioneering bacteria Gammaproteobacteria (P = 0.03) and exhibited a trend for elevated total SCFA content (P < 0.06). Independent of maternal prepregnancy BMI, HM insulin was positively associated with both microbial taxonomic diversity (P = 0.03) and Gammaproteobacteria (e.g., Enterobacteriaceae; P = 0.04) and was negatively associated with Lactobacillales (e.g., Streptococcaceae; P = 0.05). Metagenomic analysis showed that HM leptin and insulin were associated with decreased bacterial proteases, which are implicated in intestinal permeability, and reduced concentrations of pyruvate kinase, a biomarker of pediatric gastrointestinal inflammation.

CONCLUSION

Our results indicate that, although maternal obesity may adversely affect the early infant intestinal microbiome, HM insulin and leptin are independently associated with beneficial microbial metabolic pathways predicted to increase intestinal barrier function and reduce intestinal inflammation. This trial was registered at clinicaltrials.gov as NCT01693406.

Fecal microbiota composition of breast-fed infants is correlated with human milk oligosaccharides consumed

OBJECTIVES

This study tested the hypothesis that the fecal bacterial genera of breast-fed (BF) and formula-fed (FF) infants differ and that human milk oligosaccharides (HMOs) modulate the microbiota of BF infants.

METHODS

Fecal samples were obtained from BF (n = 16) or FF (n = 6) infants at 3-month postpartum. Human milk samples were collected on the same day when feces were collected. The microbiota was assessed by pyrosequencing of bacterial 16S ribosomal RNA genes. HMOs were measured by high-performance liquid chromatography-chip time-of-flight mass spectrometry.

RESULTS

The overall microbiota of BF differed from that of FF (P = 0.005). Compared with FF, BF had higher relative abundances of Bacteroides, lower proportions of Clostridium XVIII, Lachnospiraceae incertae sedis, Streptococcus, Enterococcus, and Veillonella (P < 0.05). Bifidobacterium predominated in both BF and FF infants, with no difference in abundance between the 2 groups. The most abundant HMOs were lacto-N-tetraose + lacto-N-neotetraose (LNT + LNnT, 22.6%), followed by 2'-fucosyllactose (2'FL, 14.5%) and lacto-N-fucopentaose I (LNFP I, 9.5%). Partial least squares regression of HMO and microbiota showed several infant fecal bacterial genera could be predicted by their mothers' HMO profiles, and the important HMOs for the prediction of bacterial genera were identified by variable importance in the projection scores.

CONCLUSIONS

These results strengthen the established relation between HMO and the infant microbiota and identify statistical means whereby infant bacterial genera can be predicted by milk HMO. Future studies are needed to validate these findings and determine whether the supplementation of formula with defined HMO could selectively modify the gut microbiota.

Prevalence of metabolic syndrome in obese children and adolescents using three different criteria and evaluation of risk factors

OBJECTIVE

To compare the prevalence of the metabolic syndrome (MS) in Turkish obese children and adolescents by using three different definitions and to assess the risk factors through a retrospective evaluation of anthropometric and laboratory parameters.

METHODS

Sixty hundred and fourteen obese patients (307 male, 307 female; mean age: 11.3±2.5 years) were included in the study. Medical history, physical examination, anthropometric measurements, results of biochemical and hormonal assays were obtained from the hospital records. MS was diagnosed according to the modified World Health Organization (WHO), Cook and the International Diabetes Federation (IDF) consensus criteria.

RESULTS

The prevalence of MS was found to be 39%, 34% and 33% according to the modified WHO, Cook and the IDF consensus criteria, respectively. MS prevalence in patients aged 12-18 years was significantly higher than that in patients between 7 and 11 years of age (p<0.05). Pubertal patients had a significantly higher MS prevalence than the non-pubertal cases (p<0.05). MS prevalence was also significantly higher in children who had a family history of heart disease, diabetes, obesity and hypertension as well as in those who had not been breast-fed (p<0.05).

CONCLUSION

The use of the modified WHO criteria was found to result in a slightly higher prevalence rate for MS as compared to the other criteria. The prevalence of MS in our study population was higher than that reported in most previous studies in Turkey. A positive family history, puberty and not being breastfed in infancy were shown to be significant risk factors for MS in childhood.